Provider Demographics
NPI:1730167099
Name:PRUITT, DAVID E (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:E
Last Name:PRUITT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 ATHERHOLT RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-1106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:804-598-2965
Practice Address - Street 1:935 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-2211
Practice Address - Country:US
Practice Address - Phone:434-315-5340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101233329207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VV8136DMedicare PIN
H68119Medicare UPIN
VAVV8136BMedicare PIN
H68119Medicare UPIN